In Defense of Transplantation

[Guest guest]

I'm sorry this is so long, but knew many were not members with

passwords. I'll let you decided how you feel about this article.

From American Journal of Transplantation

In Defense of Transplantation: A Reply to Scheper-

Posted 08/22/2007

B. E. Hippen; J. S.

Content

We read with disappointment the essay by Scheper- in which

she compares living organ donation to 'sacrificial violence'. Tempting

as it is to dismiss this kind of criticism as a simple provocation,

Scheper- is the founder of Organs Watch, an organization

publicly represented as exposing the egregious moral abuses of

international organ trafficking. We believe such a solemn

responsibility imposes additional obligations on both Scheper-

and on her critics, since extravagant, misleading criticism can damage

good causes and bad causes alike. Drawing on Scheper-'s past

writings and current essay, we wish to place in context and then

criticize her understanding of donation as 'sacrificial violence', her

denial of any meaningful moral distinction between 'family bonds' and

'family bondage', her mischaracterization of the achievements of

presumed consent policies in Europe, her parochial understanding of

futility, and her pernicious characterizations of transplant

professionals and of the endeavor of transplantation as a whole. After

identifying and considering Scheper-'s criticisms we judge

worthy of careful consideration, we conclude with general comments on

the standards by which criticism of the practices of transplantation

ought to be evaluated.

In previous essays, Scheper- has characterized transplantation

as 'neocannibalism', the legacy of which has been to spread a myth of

immortality to vulnerable potential recipients: '...the transformation

of a person into a " life " that must be prolonged or saved at any cost

[which] has made life into the ultimate commodity fetish'. Indeed,

until her essay in the American Journal of Transplantation, she had

argued that the waiting list for organs was itself a myth, invented by

transplant professionals solely for their personal and professional

advancement: 'The specter of long transplant waiting lists?often only

virtual lists with little material basis in reality?has motivated

physicians, hospital administrators and various intermediaries to

employ questionable tactics for procuring organs?. But this scarcity,

created by the technicians of transplant surgery, represents an

artificial need, one that can never be satisfied, for underlying it is

the unprecedented possibility of extending life indefinitely with the

organs of others'. This context is crucial to understanding

Scheper-'s argument that all living donor?recipient

relationships involve 'sacrificial violence', in which 'family bonds'

are synonymous with 'family bondage'. Since for Scheper-, the

'need' for a transplant and the attendant illusion of shortage is a

collective delusion eagerly supported by avaricious transplant

professionals, it follows that their use of terms such as 'altruism'

and 'family bonds' as alternative descriptors of the donor?recipient

relationship is mere propaganda. Perhaps, Scheper-'s arguments

in her AJT essay, which now exhort deceased donation, can be

understood as an exercise in realpolitik: Transplantation may be based

on a terrible lie, but better to focus one's efforts to turn its

voracious appetite for organs from the dead instead of from the

living. It is immaterial to Scheper- that her view is utterly at

odds with conventional understandings of transplantation and

donor?recipient relationships. As with any unfalsifiable conspiracy

theory, the widespread rejection of her thesis among transplant

professionals and medical ethicists who write on transplantation

ethics only serves to prove how entrenched this delusion has become.

A conspicuous feature of Scheper-'s criticisms is an

indifference to countervailing arguments and evidence. For example,

she has elsewhere argued that the lower rate of consent for deceased

donation among Black and Hispanic families is best explained as '...a

political act of considered resistance' against what she believes they

see as the oppressive hegemony of transplant professionals. This is

incompatible with the empirical evidence that has been collected on

the issue, which shows that the most important variable predicting a

lack of consent for donation from Black and Hispanic families is a

lack of foreknowledge regarding the decedent's wishes[5,6] and

misconceptions regarding the financial burdens of consenting to

deceased donation and the concept of brain-death. Though she denies

any meaningful moral difference between family bonds and 'family

bondage'given that '...Families are often violent and predatory, as

inclined to abuse and exploit as to protect and nurture their members'

Scheper- offers no reason to accept this bleak view of human

relationships. Moreover, it is simply unjustified to hold that the

inherent moral asymmetry involved in giving the 'gift of life' is only

(or even often) imbued with psychological indenture and resentment.

Instead, an approach more receptive to the raw complexity and

ambiguity of the moral lives of thoughtful human beings paints a

picture of relationships slightly more diverse and textured than one

of master and slave.[8] In fact, the anthropologist and social

scientist who coined the term 'Tyranny of the Gift', emphasized and

elucidated this diversity,, and more than fifty studies of

psychosocial outcomes of living donors demonstrated either no change

or a positive improvement in the psychological health of the vast

majority of them.

Scheper-'s indifference to, or unfamiliarity with, evidence

concerning the issues she addresses is exemplified in her allusion to

the alleged success of presumed consent policies in European

countries. Her brief mention offers no reference to the manifest

ethical concerns regarding presumed consent (reviewed in, overlooks

the fact that such policies are not enforced in countries with the

most robust rates of procurement,and at any rate are not causally

related to improved organ procurement rates compared to countries

without such policies.

So, we turn with skepticism to Scheper-'s call for the

'restoration' of a 'social ethic' to transplantation, with the

unfortunate implication that such an ethic was somehow lost.

Acknowledging that deceased donor organs alone cannot attenuate the

burgeoning need for organs, Scheper- admonishes the profession

as '...unwilling...to examine the waiting list to see if futile cases

cannot, in good faith, be removed and to establish age limits that

would decrease the list by several thousand', She acknowledges that

such a draconian, arbitrary measure would not be 'palatable', and that

such patients would likely pursue transplantation through illicit

means, including international organ trafficking, a point not lost on

others opposed to trafficking. Given the salutary outcomes she herself

cites for elderly recipients after transplantation compared to

dialysis, it seems that when Scheper- characterizes this

practice as 'futile' she must mean not that it is futile for the organ

recipients themselves, but, rather, that it is futile with respect to

providing organs for persons who are assumed to no longer be able to

meaningfully contribute to society. She justifies this by an appeal to

a 'cultural norm in American society' in which '...it is not generally

expected that children be unstintingly devoted to their parents',. Not

only does this norm overstate the act of being a living donor as

'unstinting devotion', but it is one which is also apparently

overlooked by the estimated 44 million family caregivers in the United

States, who do not find their unstinting devotion either unusual or

morally troubling. Curiously, Scheper- fails to see that her

view is simply a species of arguments from social worth, which

dominated the early debates regarding the allocation of dialysis, the

'unpalatable' moral consequences of which resulted in vast reforms to

eliminate such considerations from the allocation of life-saving

therapy.

As a practical matter, even if excluding candidates by age could

withstand moral and legal scrutiny, and even if the subsequent,

predictable increase in underground organ trafficking could somehow be

attenuated, we and Scheper- should be concerned with likely

effects that this measure would have on living donation. Without other

means of pursuing transplantation, elderly recipients would likely

rely on living donors even more than they currently do. And, as much

as she might wish otherwise, transplant physicians who do not share

Scheper-'s understanding of what is, and what is not, 'futile'

treatment are unlikely to refuse medically qualified elderly

recipients a transplant from a willing living donor.

Though we reject Scheper-'s premises, we are obliged to salvage

and highlight issues that she correctly identifies as worthy of moral

attention. The gender imbalance among living donors noted by

Scheper- is real, may in some circumstances be a product of

power asymmetries in certain family relationships and is worthy of

further scrutiny. The flourishing of international organ trafficking

has generated demonstrable physical and psychological damage to

vendors and recipients, and is an indelible moral stain on reputable

transplantation. The growth in the number of elderly transplant

candidates, a phenomenon which will only increase with the success,

not the failure, of preventive medicine, is but the latest example of

technical innovation resulting in the exchange of one set of problems

(survival) for others (scarce resource allocation). The projected

increase in the number of prevalent dialysis patients, and therefore

the number of potential transplant recipients in the next 5 and 10

years, concomitant with the comparatively stagnant growth in the

number of deceased donor organs, will only increase the pressure on

traditional living donors to quell the desperation bred of a wholly

inadequate public policy. These are the circumstances which threaten

to render particularly vulnerable living donors more so. These are

problems that urgently warrant our moral attention, which is why it is

crucial, indeed, morally obligatory, that the challenges they pose are

accurately explained and scrutinized.

To this end, commentators on and chroniclers of transplantation have

never shied from criticism. The standard by which criticism is judged

is not whether the field of transplantation is helped or hindered, but

rather whether such criticisms can be supported and substantiated by

sound arguments and attention to the available evidence. Such a

standard does not imply that such criticism must merely serve as

handmaiden to the advancement of transplantation. Reneé Fox and Judith

Swazey, after producing two decades' worth of exemplary critical

scholarship in the field, publicly withdrew from their research, after

concluding that public expenditures on organ transplantation could not

be justified in a society which fails to provide universal access to

health care. The critical efforts of anthropologists, sociologists,

philosophers, economists and lawyers have morally improved the

practice of transplantation, and its workings continue to be subjected

to warranted scrutiny. It is also true that transplantation is

predicated on a public trust informed and enhanced by criticism, but

not entirely impervious to vandalism. While Scheper-'s

concern with protecting vulnerable people is admirable, her flawed,

unfortunate essay is a reminder to those struggling to advance a

morally informed practice of transplantation that maintaining the

public trust obliges us to distinguish between the two.

[Guest guest]

Barb,

I got the reply to Scheper-, in full from Medscape, but am

unable to find her original essay (s). Do you have a link to what they are

replying to?

Thanks,

Penny T

[Guest guest]

Hi Penny,

I've uploaded the original Scheper- essay into the

Files/Transplant info folder (see recent message about a new file

upload). The abstract of the article is shown below. I agree with you

that it is useful to read her essay before reading the critical

comments. She makes some interesting, and sometimes disturbing,

observations.

Am. J. Transplant. 7: 507-511 (2007)

The tyranny of the gift: sacrificial violence in living donor

transplants.

Scheper- N

Organs Watch, 232 Kroeber Hall, University of California-Berkeley,

Berkeley, CA, USA. nsh@...

Medical anthropology can bring to living donor transplant useful

insights on the nature of gifting, family obligations, reciprocity

and invisible sacrifice. Whereas, ethical reflections and debates on

the marketing of tissues and organs, especially sales by living

strangers, have proliferated to the point of saturation, the larger

issue of the ethics of " altruistic " donation by and among family

members is more rarely the focus of bio-ethical scrutiny and

discussion today, though of course it was much debated in the early

decades of kidney transplant. As the proportion of living over

deceased donors (especially of kidneys) has increased markedly in the

past decade, the time is ripe to revisit the topic, which I shall do

via three vignettes, all of them informed by my 10 years as founding

Director of Organs Watch, an independent, university-based,

anthropological and ethnographic field-research and medical human

rights project. Whereas living-related (altruistic) and living-

unrelated (commercial) donation are often treated as very different

phenomena, I will illustrate what social elements are shared. In both

instances, paid kidney sellers and related donors, are often

responding to family pressures and to a call to " sacrifice " .

Comment in:

Am J Transplant. 2007 Jul;7(7):1695-7.

Am J Transplant. 2007 Mar;7(3):497-8.

PMID: 17250554

Best regards,

Dave R.

> I got the reply to Scheper-, in full from Medscape, but

am unable to find her original essay (s). Do you have a link to what

they are replying to?

[Guest guest]

,

Thank you very much, you are very clever. Thank you also for all the

research and support you give everyone. In the words of my daughter, The

article (both actually) has lots of " big words " . Might take a bit of wading

through, but I have a free morning, so am looking forward to it.

Penny T (in Australia)

Ps you can get mangosteen juice and Goji juice here too (down under), but

I'm not game to try anything that isn't proven